Title Page
-
Date
-
Child's full name
-
Centre location
Page 2
Details of person completing this record
-
Name (First & Last)
-
Are you a staff member?
-
Position/role
-
Date and time record was made
-
Signature
Child details
-
Child's name listed in title page section.
-
Age
-
Gender
Incident details
-
Centre location is in title page
-
Incident date
-
Name of witness (First & Last)
-
Witness Signature
Page 3
-
Type of incident
-
Time of onset of illness
-
What are the symptoms?
- Allergic reaction (not anaphylaxis)
- Headache
- Internal injury/ infection
- Rash
- Seizure/ unconscious
- Symptoms of a cold/flu
- High temperature
- Infectious disease
- Poisoning
- Respirator
- Stomach pains
- Other
-
Please list symptoms
-
Any other additional information
-
STOP! Call HQ immediately on 0450 678 062
-
Have you called HQ?
-
Who did you speak to?
-
Was a child missing?
-
Who found the child?
-
How long was the child missing for? (answer is in minutes)
-
Any additional information
-
Remember DETAILS are important - who, what, when, where, how.
-
Circumstances leading up to the injury/incident (please include location if injury occurred at Inspire)
-
Cause of injury
-
Please select injury
- Abrasion/ Scrape
- Amputation
- Bite wound
- Broken bone/ fracture/ dislocation
- Bruise
- Burn/ Sunburn
- Choking
- Concussion
- Crush/ Jam
- Cut/ open wound
- Drowning (non-fatal)
- Electric shock
- Eye injury
- Head injury
- Ingestion/ inhalation/ insertion
- Nose bleed
- Sprain/ Swelling
- Stabbing/ Piercing
- Tooth
- Other
-
STOP! Call HQ immediately on 0450 678 062
-
Have you called HQ?
-
Who did you speak to?
-
Photo of injury
-
Body part affected i.e. right knee
-
Remember DETAILS are important - what, when, where, how.
-
Where did this incident occur?
-
Circumstances leading up the incident
-
Cause of any injury?
-
Photo of injury/ body part affected
-
Remember DETAILS are important - who, what, when, where, how.
-
Please describe what happened prior and during the incident
Action Taken
-
Details of action taken (including first aid, administration of medication etc)
-
Did emergency services attend?
-
Was medical attention sought from a registered medical practitioner/ hospital?
-
What steps have been taken to minimise and prevent this type of incident in the future?
-
Additional notes
Page 4
Parent notification (including attempted notifications)
-
Parent/Guardian name (First & Last)
-
Date and time
Responsible Person notification
-
Responsible Person's name (First & Last)
-
Date and time
Other agency notification (if applicable)
-
Agency name
-
Name of person contacted
-
Date and time
Page 5
Parental acknowledgement
-
Name of Parent/Guardian (First & Last)
-
Date
-
Signature
